Osteoporosis & Fracture

A 55- year old lady injured the middle of her back (thoracic spine) when she had lifted a heavy suitcase down from the garage roof to the floor. At the time she felt a severe and very sharp pain in the middle of her thoracic spine. A few days later she came in for a physio assessment. She described “deep vice like constant pain” in the middle of the spine radiating around the ribs. It was worse with the movement of the spine. She was finding it painful to stand straight and was having difficulty sleeping. It was better sitting supported or lying on her back for short periods. Wearing a bra was too uncomfortable.

On physical assessment, she was a little overweight but had a slight curvature to her middle back (kyphosis). All her spinal movements were very guarded and limited. When I felt her spine, she reported a very painful and sensitive area in the centre of the back at around the middle of her spine T7 and T8 levels.

It is very important to take time to thoroughly question a patient about their medical history as this may reveal important information which may shape our diagnosis and management.
In this lady’s case, she had several risk factors for Osteoporosis (a medical condition in which bones become brittle and fragile).

Risk factors in medical history:

Early menopause which happened at 40 (normal is around 52)
She had stopped Hormone replacement therapy (HRT) at 42 due to suspected breast cancer which fortunately was ok.
She had taken Steroids (Prednisolone) for 1.5 years a few years ago
Her mother had osteoporosis.
Diabetic (Type II)
Probable low Vit D (fair skin and rarely exposed skin to the sun)

I suspected that my patient may have sustained a compression fracture of a vertebra during a non-traumatic event due to having suspected Osteoporosis. After plenty of positive reassurance and education, I suggested that she saw her GP to have a spinal x-ray and to check out her bone health and to get some stronger painkillers I faxed a letter to her GP underlying my concerns.

My patient returned to see me 8 weeks later. She had an x-ray which confirmed that she had an anterior wedge fracture at T8 in her thoracic spine. She had also had a bone mineral density scan (DXA) which revealed that she did have moderate osteoporosis of her spine but not in her hips. Blood tests also revealed very low levels of Vitamin D. Her doctor had prescribed Alendronic Acid, Vitamin D3 and calcium for bone health. Her pain was well controlled, and she was much more comfortable moving.

Treatment

When someone has osteoporosis, physical activity and exercise have an important role in the management of this condition – it promotes bone and muscle strength and reducing the risk of falling and managing symptoms. See reference 1 below.
However, people are very fearful that they may do more harm and are frightened that they may cause more fractures by exercising. People with painful vertebral fractures need some clear and prompt guidance on how to adapt movements in their day-to-day living and how to go about exercising and should be positively encouraged to do so.

Before this incident, my patient participated in 2 sessions of aqua aerobics per week and had started to swim. She wasn’t someone that was at particular risk of falling. At this session, we discussed my patient’s concerns and I taught safe techniques for moving, bending and lifting including the ‘hip hinge’ and ‘squat’. I recommended at this stage not to bend forward into end range positions. We worked on improving straight spine posture. Walking in a slightly bent forward posture is extremely tiring and can cause pain and does not promote good spinal mechanics.

I suggested that low impact exercise after having a vertebral fracture was a good way to start exercising. My patient started walking every day during her lunch hour for 15 minutes per day building up to 20 or 30 mins. I also taught her 6 easy Pilates exercises to start building confidence in moving and to strengthen her core. She was going to start doing these 3 times per week initially.

I then saw my patient every 2 weeks for a total of 6 sessions. Through this period, we progressed the exercises to help:

Build bone and muscle strength

3 or 4 exercises 2-3 days per week – 8-12 reps with appropriate weight/resistance band
Daily weight bearing/impact activities. We varied the exercises to target different areas. We progressed from a steady pace to faster paced walking, to walking with a backpack and weights/poles. Aqua aerobics was resumed after 4 weeks.
Improve balance
Some exercises were progressed to single leg work.

Improve pain, posture and movement

Throughout the sessions, we promoted good straight posture and safe movement patterns.

At the end of our 6 sessions, my patient was enjoying doing more exercise and felt very confident in the management of her condition. She no longer felt scared or restricted.

Conclusion

I based my programme using the new expert consensus guidelines drawn up recently by the National Osteoporosis Society which provides advice to clinicians such as ourselves to promote Strong, Steady and Straight so that we can help people take part in safe and effective exercise to build bone strength and reduce fracture risk. As physiotherapists, we are well placed to assess patients, regardless of their age and fragility and to work out a suitable programme to help with Osteoporosis. (Ref 2.)

It is recommended by the NHS that patients who have been prescribed bisphosphonates drugs for Osteoporosis such as Alendronic acid (ref 3.) should at least have a telephone follow up with their GP 3 to 6 months after starting treatment. The need for continued treatment should be re-evaluated periodically based on the benefits and potential risks of the drugs for individual patients particularly after 5 or more years of use.

Mr Nick Birch a spinal consultant has recently set up an excellent service in Northamptonshire called MY BONE HEALTH offering ‘radiation free’ bone mineral density scanning providing immediate bone mineral density results and the very best advice depending on the results of the scan. This can help people to monitor and manage their bone health. Read more at https://www.mybonehealth.co.uk/

Claire Todd

Ref. 1 Osteoporosis and exercise

Ref. 2 NHS Guidelines

Ref. 3 Osteoporosis and Biphosphonate Treatment